SAC Summer Camp Application

Posted

    Student Information

    Student Name:

    School:

    Sex:

    Student Age:

    Birth Date:

    Grade:

    Race: African AmericanAsianHispanicWhiteOther

    Other:

    Is this application for multiply children? YesNo
    If so, how many?

    Program Interest:

    Training Experience / Background:

    Parent/Guardian Information for Minors Only

    Name of Legal Guardian:

    Relationship:

    Physical Address:

    Mailing Address:

    Phone Number:

    Alternate Phone Number:

    Email Address:

    SAC Member? YesNo

    Emergency Contact Information

    Name #1:
    Phone Number:
    Relation:

    Name #2:
    Phone Number:
    Relation:

    Family Doctor:
    Doctor's Phone Number:

    Scholarship Information:

    Will your child be applying for a scholarship? YesNo

    Total Parent(s) / Family Income:

    Student GPA / Academic Record

    Has the student had any behavioral issues at school? YesNo

    If yes, please explain:

    Media Release:

    The above registered art student has permission to be photographed by the South Side Arts Complex for use on its website, promotional materials, or during local newscast or print interview.
    *Please Initial:

    Liability:

    The South Side Arts Complex does not accept responsibility for any liability from any bodily injuries sustained, or for loss or damage of any personal articles, to/of students while on the premises or while participating in any activity sponsored by the South Side Arts Complex. In the event that medical attention is required due to accident or illness, the South Side Arts Complex shall, without accepting responsibility, seek such medical services, as it deems necessary and appropriate through EMS/911 and/or local hospitals. All students/parents are expected to sign a Waiver of Liability Form.

    *Type your Full Name to accept:
    Full Name: Date:

    Medical Information:

    Please tell us, in full, about any medical/health, and/or developmental or behavioral conditions, including speech, occupational therapy, or the like, past or present, and any other pertinent information that might aid in the enhancement of your child’s camp experience. Use a separate sheet as necessary. We strive to care for children with various needs, but we need your full input to succeed.

    Please list all allergies, current medication(s), vitamins, inhalers, etc. Please note that if your child requires an emergency allergy kit (ie. Epipen, bee sting kit, or inhaler, etc), you must supply medication labeled with child’s name and detailed instructions on our Permission to Administer Medication form to the summer camp office prior to your child’s attendance. Kits are returned if unused.

    **Once your application has been processed someone will contact you from the Arts Institute division to provide information for your enrollment.